Failure to Report Abuse Allegations Resulting in Continued Resident Harm
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the abuse coordinator and the State Agency, as required by their own policy and federal regulations. One resident, who was not cognitively intact and had diagnoses including Alzheimer's Disease and agitation, was subjected to rough and forceful care by a CNA during incontinence and clothing changes. Video evidence showed the CNA pressing the resident's hand to her chest, roughly adjusting her legs, and forcefully wiping her perineal area, causing the resident to grimace, moan, cry, and take a defensive posture. The CNA also made inappropriate comments about the resident's family and disregarded the use of required equipment during care. Another resident, who was cognitively intact, reported that the same CNA was rough during care, pulled her clothes off roughly, and ignored her attempts to hold onto a safety bar, resulting in distress and fear for her safety. Despite these incidents, the facility did not immediately report the allegations to the State Agency or escalate them according to policy. Documentation showed that concerns about the CNA's rough handling had been previously discussed verbally, but no formal report was made following new allegations. Staff who witnessed the abusive behavior did not report it, with one agency CNA stating she did not report the incident because she felt it would be her word against the other CNA's. The failure to report allowed the abusive behavior to continue, resulting in further distress and harm to the residents involved. The deficiency was identified as Immediate Jeopardy due to the ongoing risk and harm to residents from unreported abuse. The facility's lack of timely reporting and failure to follow established procedures for handling abuse allegations directly contributed to the continuation of abusive behavior by the CNA. The survey findings were based on observation, record review, and staff and resident interviews, which confirmed that the required notifications and protective actions were not taken in a timely manner.
Removal Plan
- Terminate V3's employment with the facility.
- V2 and V18/Assistant Director of Nursing perform education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.
- V15/Risk Manager review with V2 (designated abuse coordinator) policy Abuse and Neglect Procedures specifically for reporting and escalating abuse allegations immediately for review and reporting.
- V1/Chief Nursing Officer, V2, and V15 review LTC Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.
- V2 review with the V18 the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information. V2 and V18 then educate all staff on shift on the above stated policy.
- Staff not working day shift are called by V18 and V2 and the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.
- Remainder of staff not working or reached by phone will be required to receive education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information prior to working next shift by V2 or V18 and will be tracked on sign-in sheet.
- LTC Abuse and Neglect Procedures Policy is added by the V2 to contracted staff orientation packet for review prior to first shift.
- An Emergency QAPI/Quality Assurance and Performance Improvement discussion is held with V1, V2, V17/Social Services, V20/Medical Director and V15 to review the resident audit findings performed and reviewed investigation. On-going audit plan is created, to include monitoring of any concerns/complaints to ensure appropriate follow-up to include reporting of any abuse per policy. Five residents a month will be interviewed by Social Services or V2/designee about cares received and any concerns regarding staff. These audit findings will be reviewed by V17 and the V2 and reported monthly by the V2 on the QAPI scorecard and at the quarterly Quality assurance meeting.
- V15 will monitor all incidents of patient injury and meet monthly with V2 to review for trends for further review.